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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQIIIN, PHONE (209)468-3420 P 0 BOX 2009,` STOCSTON, CA. 95201 w PERMIT EXPIRES 1 YEAR FROM E ISSU13DY z (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This I: application is made in c=Wliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San i Joaquin County Public Health Services. ,} Job Address. hEZE RL fa is City .0 5,03 .. A Lot Size/Acreage _ �� Z t Owner's Name U1L.L, TDE 1VE LO�fY) Address pQ. aox 477.E CW-41�,� Phone iy ContractorL�l A--,PE✓1CL0E &6Address LicenseNo.sPhone 3 E , TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service hell ❑ PUMP INSTALLATION O .i,_.... €SYSTEM REPAIR,[] OTHER O Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 Industrial ❑ Open Bottom © Manteca Die. of Well Excavation Dia. of Weil Casing 11 Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public Cl Other Cl Delta Depth of Grout Seal Type of Grout 11 Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction O Well Diameter Sealing Material i Depth Depth hiller Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION j(3 REPAIR/ADDITION i I DESTRUCTION l I (No septic system permitted if public sower is _ available within 200 feet.) Installation will serve: Residence✓ Commercial_ Other T Number of living units. DI&L Number of bedrooms 4— " Character of soli to•depth of 3 feet: + Water table depth SEPTIC TANK ® Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ ii Method of Disposal m _ Distance to nearest: Well Foundation .Property Line LEACHING LINE 01 No. ii Length of lines 4 — 46 ;,GACWTotal length/size FILTER BED... Cl Distance to nearest: Walt A n I Foundation Property Line 1 1 SEEPAGE PITSJ � DepthSite w��_?, _ Number SUMPS L1 Distance to nearest: Well1 I/1► Foundation 2 o _ Property Line.- DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not ot employ any person in such manner as to become subject to workman's compensation tows of California."Contractor's hiring or sub-contracting signature e. Certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion lays of California.,, The applicant m t call f r all required ins tions. Complete drawing on reverse side. Signed Title: 1 Date: z.— FOR EPARTMENT USE ONLY Application Accepted by - Y Date2 res d Z Pit or Grout Inspection by Date Final Inspection b Date�� Additional Comments: I Applicant- Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin,.-P O Box 2009, Stkn, CA 95201 FEE MOUNT DUE - AMOUNT REMITTED K RECEIVED BY DATE PERM17-N6 INFO p H . E 17-2 tREV.iitiSl EN 14211 LLL fi\.7 /